Patient Initial Intake Form
We are looking forward to meeting with you.
Please fill out this form prior to your visit to save time.
- You can print and bring in the form to your visit.
- You can email to my HIPPA compliant email address (after password protecting under properties)*
- Or fax to: 3236550860
*Save the form to your desktop and then email to email@example.com and in the RE: line say New patient consult – attach the pdf. This is a HIPPA compliant email address – you can password your completed and saved pdf with your 6-digit date of birth thru document properties.